Health

Summary

C complained about the board's handling of their grandparent's (A) consent for a surgical procedure. A had vascular dementia (a common form of dementia, caused by problems in the supply of blood to the brain) and was resident in a care home. A had Adults With Incapacity (AWI) status and their child had Power of Attorney (PoA) for their welfare and financial needs. A was admitted to hospital due to abnormal liver function tests. It was subsequently decided that they should undergo an invasive procedure.

C complained to the board that A’s consultant obtained their consent for the invasive procedure without any contact being made with A’s next of kin or listed PoA. In response to C’s complaint, the board said that the relevant consultant considered that A had the capacity to make this decision. The board reiterated that the presence of a PoA does not mean that an individual is unable to make their own decisions. They said that it was the consultant's clinical professional opinion at that time that A had the capacity to consent to the invasive procedure as they were aware of being previously offered the procedure and said that they wanted something done.

We took independent advice from a mental health nurse adviser. We found that there was sufficient information available in the clinical records to highlight A’s potential capacity issues and it was unreasonable that this was not properly considered. We found that A’s consent for the procedure was not properly obtained. In light of this, we upheld the complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and their family for not obtaining consent properly and deficiencies in the documentation surrounding the assessment of A's capacity, PoA arrangements and consent process. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• That the board take steps to ensure full compliance with the requirement to assess and review patients’ capacity where necessary.
• That the board take steps to ensure that staff fully complete the MDT assessment documentation to ensure full information relating to capacity and welfare arrangements is recorded and available.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the standard of medical treatment provided to their late spouse (A) by the board following diagnosis and treatment of upper tract urothelial cancer (a type of kidney cancer). A’s condition deteriorated and they died. C complained that clinicians failed to, amongst other things, communicate with them in a reasonable way about treatment options and take reasonable action in response to A’s clinical condition.

We took independent advice from a urology specialist (concerning the male and female urinary tract, and the male reproductive organs) and a renal specialist (concerning the kidneys). We found that A’s cancer had likely been more aggressive than originally suspected. However, given the information available at the time, the option of treatment offered to A had been a reasonable approach. We also found that the board had failed to adequately document that all treatment options had been discussed with A, and that a specialist renal cancer nurse should have been available to the family sooner. We found that had A’s treatment been carried out sooner (and in line with cancer waiting time standards), it may have improved their health outcomes. For these reasons, we upheld this aspect of C’s complaint.

C also complained that during a hospital admission the board had failed to reasonably manage the removal of A’s nephrostomy tube (a catheter inserted through the skin and into the kidney) causing them to suffer an arterial trauma (or bleed). We found that bleeding is a recognised complication of such a procedure and there was no evidence to indicate any failings in the removal of the tube. We did not uphold this aspect of C’s complaint.

C further complained that when A’s condition deteriorated following dialysis, unit staff advised the family to take A home, or to take them to the emergency department themselves. C also complained that there had been no end-of-life plan in place for A. We found that there was insufficient evidence to determine what advice had initially been offered to the family by unit staff. However, we found that the process around the decision-making to admit A for ward care had been appropriate, and although there had been no end-of-life plan in place, the ‘wait and see’ approach to treatment had been reasonable in this case. Therefore, on balance, we did not uphold this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• The board should ensure all discussions between patients and clinicians are clearly documented in line with required standards.
• The board should give consideration to the use of specialist renal cancer nurses in supporting patient diagnosis/patient management from an early stage.
• The board should review urgent suspicion of cancer referrals to address treatment waiting times, ensuring that there are appropriate mechanisms in place to monitor progress from diagnosis to definitive treatment.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment provided to their parent (A) by the board. A was admitted to the hospital due to a catheter blockage. On examination, it was determined that A required specialist treatment and an ambulance transfer to another hospital within the board was arranged. It took approximately six hours for the ambulance to arrive by which time A was showing signs of sepsis (a life-threatening reaction to an infection).

Antibiotics treatment was initiated on A’s arrival and they had regular washouts of their catheter and continuous irrigation due to blockages and bleeding. A had ongoing uro-sepsis and required blood transfusions. A suffered a heart attack during their admission and blood-thinning medication was prescribed. However, this made the bleeding at the catheter site increase. A died in hospital several days later.

C complained to the board about A’s care and treatment but the board did not identify any failings. The board did identify and apologise for failure in communication with C. C remained unhappy and asked us to investigate. C complained that the staff in the first hospital had unreasonably delayed in treating A with antibiotics. C complained that staff in the second hospital subjected A to unnecessary pain while irrigating their catheter. C also complained that staff failed to identify that A’s catheter had been incorrectly placed. C complained about a decision to prescribe A with the anti-coagulant. C also complained about the palliative care given to A.

We took independent advice from a consultant in emergency medicine and a consultant urological surgeon (specialist in the male and female urinary tract, and the male reproductive organs). We found that staff in the first hospital had unreasonably delayed in treating A with antibiotics and we upheld this aspect of C’s complaint. We found that the care and treatment given to A in the second hospital was reasonable. However, we considered that staff had failed to recognise that A’s catheter was in the incorrect position within a reasonable timescale and therefore upheld this aspect of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for the delay in treating A with antibiotics until they had been transferred to the specialist; and in recognising that A’s catheter was in the incorrect position. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients diagnosed with sepsis should have antibiotics administered promptly and without delay.
• Patients undergoing catheter insertion should be closely monitored so that any complications such as incorrect placement are recognised and treated without delay.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the practice failed to provide their late spouse (A) with appropriate care and treatment. C said that GPs at the practice failed to see their partner at face to face consultations where they could observe their reported symptoms of facial weakness. Phone calls were made on a Friday and Monday but A was still not seen despite contacting the Out Of Hours Service (OOHS) at the weekend. A died a few days later of a stroke.

C felt that the practice should have seen A face to face rather than via telephone consultations. The practice believed that the GPs involved had provided A with appropriate care and treatment based on their reported symptoms at the time.

We took independent advice from an appropriately qualified adviser. We found that the practice had provided a reasonable level of care based on A’s reported symptoms. Therefore, we did not uphold the complaint but provided the practice with feedback concerning the standard of record keeping.

Summary

C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency Unit, A was transferred to another ward which C was advised was a red pathway ward (a ward for COVID-positive patients). A was discharged over a week later.

C complained to the board about A’s transfer to a red pathway ward and had not been satisfied with the explanation the board provided. C also complained about the standard of nursing care, the decision to discharge A, and that the board failed to arrange follow-up care for A following their discharge.

We took independent advice from a nurse and a consultant geriatrician (specialist in medicine of the elderly). We found that, while the decision to transfer A to a red pathway ward had been reasonable and appropriate in the specific circumstances, the board had not reasonably explained the decision to C. Therefore, we upheld this part of C’s complaint.

We also found that the standard of nursing care and decision to discharge A was reasonable. The board also made the relevant referrals to the appropriate community services after A’s discharge. Therefore, we did not uphold these aspects of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not explaining the rationale behind the transfer of A to a red pathway ward. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the medical practice failed to provide reasonable care and treatment to their spouse (A) after they presented with a lump in their right breast.

We took independent advice from a GP. We found that the time taken to refer A to hospital when they first consulted the medical practice with the lump in their right breast was unreasonable. It was also unreasonable that the referral was not marked as urgent.

The medical practice had carried out a detailed review of A’s care and had accepted that there was a complete systems failure in the care and treatment provided to A. They had made a number of changes which we welcomed and considered were appropriate. Nevertheless, we found that they had not fully acknowledged their specific role and responsibility in relation to the failings which had occurred given their responsibilities for the supervision, training and actions of their employed staff.

We also identified additional issues not addressed by the medical practice in their consideration and response to the complaint. In particular, that the medical practice should have a system in place to ensure any outstanding referrals were identified when a colleague is unexpectedly absent due to sickness or ill-health and that it was unreasonable that A was not contacted by the medical practice after the cancer diagnosis given the significance of the diagnosis and their delay in sending the referral and marking it as urgent. We also found that the medical practice did not appear to have considered their duty of candour responsibilities in this case. Therefore, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C and A for the failings identified. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients should receive appropriate assessment and referral in line with relevant guidelines. Patient referrals should be reviewed and actioned when the responsible member of staff is absent unexpectedly. Where appropriate, patients should be contacted after receiving a significant diagnosis. This should include when the practice become aware that harm has occurred as a result of an unintended incident in healthcare to take into account duty of candour responsibilities, individual roles and their role responsibilities in making sure this happens.

In relation to complaints handling, we recommended:

• The practice should ensure that, where failings have been identified during a complaint investigation, the investigation and response fully acknowledges and take responsibility for the failings and ensures there is appropriate learning across the practice.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained that the board took too long to offer them steroid/local anaesthetic injections for vulvodynia (chronic pain or discomfort in the vulva). C felt this was dismissive and unsatisfactory. The board said that C did not receive the treatment initially as it was not clinically appropriate at that time. They said in order for the treatment to be effective, there should be a locally tender area to inject which C did not have. The board added that it was important to note that the treatment is unlicensed and so is only to be considered for use when definitely clinically indicated.

We sought independent clinical advice from a consultant. We found that it is right for the board to have a cautious approach to the use of unlicensed treatment. We noted that the treatment C received for many years was reasonable. However, it was later indicated that C had developed a localised area of pain and it would have been reasonable to discuss the treatment with C at that point.

We considered that whilst the care and treatment provided to C was generally reasonable, the board should have discussed the treatment option of steroid/local anaesthetic injections earlier than they did. For this reason, on balance, we upheld C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to C for not discussing the pros and cons of steroid/local anaesthetic injections as a treatment option or offering C the chance to decide whether or not they wanted to try this treatment. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Patients attending vulval pain clinics should be fully informed about their condition as well as the pros and cons of available treatments. Staff caring for patients attending vulval pain clinics should be aware of the full range of treatment options so that they are able to provide holistic care and advice to patients.

In relation to complaints handling, we recommended:

• Complaints should be responded to in line with the Model Complaints Handling Procedure (MCHP) and issued within the expected timescale of 20 working days. If the board are unable to meet the 20-working day deadline, updates and a new deadline should be issued to C in line with the MCHP.
• Letters of complaint received by the board should be logged and forwarded as appropriate to the complaints and feedback team.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.

Summary

C complained about the care and treatment they received from the board having required hip surgery following a fall. Specifically, C was concerned about the type of hip surgery they received, their post-operative care, the arrangements made for their discharge home, and the way in which the board had responded to their complaint. In responding to C, the board did not uphold the failings they had identified, and they provided a rationale for the type of surgery C received, and for the care and treatment given.

We took independent advice from an orthopaedic surgeon (specialist in the treatment of diseases and injuries of the musculoskeletal system). We considered the procedure chosen for C to be evidence based and appropriate to their particular circumstances. We also found the post-operative care and discharge planning for C to be reasonable. Finally, we considered the board’s complaint response to have appropriately responded to the matters they had complained about. Therefore, we did not uphold C’s complaints.

Summary

C complained on behalf of their parent (A) for whom they hold power of attorney. C complained that the practice had incorrectly diagnosed and treated A with chronic back pain. C stated that A was later admitted to hospital with a fractured back and pneumonia.

The practice advised that there was nothing to clinically suggest a fracture at the time and it would not have altered treatment. They noted that A did not have pneumonia as per hospital discharge.

We took independent advice from a GP. We found that a thorough physical examination was undertaken which did not raise concerns of a fracture. We also found that appropriate pain relief is the only immediate treatment for vertebral fractures. There were no symptoms of pneumonia when the patient was seen by the GP and no suggestion of pneumonia in the medical records. We did find one mention of pneumonia in a letter between two third party medical professionals, who were not involved in A’s hospital care. Therefore, we did not accept this as evidence of a pneumonia diagnosis. In light of this, we found that the overall care and treatment provided to C was reasonable and did not uphold C’s complaint.

Summary

C complained about the care and treatment their adult child (A) received from the practice. A had undergone surgery to remove infected fluid on the right lung. Gabapentin (an anticonvulsant medication primarily used to treat partial seizures and neuropathic pain) was prescribed to manage nerve pain at the incision site. The practice later stopped prescribing gabapentin and A’s mental health deteriorated significantly.

C complained about the abrupt withdrawal of gabapentin. They highlighted that gabapentin had been prescribed to manage ongoing nerve pain following surgery and noted the risks of sudden withdrawal. The practice stated that prior to the discontinuation of gabapentin there had been an increase in early requests for renewal of medication, which caused concern. A had not attended appointments with the GP or with cardiology (specialists in diseases and abnormalities of the heart). The GP felt that they could not justify further prescription of controlled drugs without seeing the patient.

We took independent advice from a GP. We found that there was no record of any significant harm from gabapentin or evidence of overuse, or had there been any discussion around reducing or stopping gabapentin. We noted that gabapentin is known to cause problems during the withdrawal period and it should therefore be withdrawn slowly. We also found that no withdrawal support was given. In light of this, we considered that the practice had failed to appropriately manage A’s prescription for gabapentin and upheld C’s complaint.

We also found failings in the practice’s handling of C’s complaint.

Recommendations

What we asked the organisation to do in this case:

• Apologise to A for abruptly stopping gabapentin. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.
• Apologise to A for the complaint handling issues. The apology should meet the standards set out in the SPSO guidelines on apology available at www.spso.org.uk/information-leaflets.

What we said should change to put things right in future:

• Complaint acknowledgements should include all the information required by the Model Complaints Handling Procedure. Points of complaint should be agreed with the complainant at the outset. Points of complaint should be addressed in the response. Care should be taken with the tone of the response.
• GPs should be familiar with the guidelines for withdrawal of medicines associated with dependence.
• The practice should have a policy around how they contact patients especially when their phones are unobtainable. Alternative modes of communication like home visit, letter or taking help from a household contact to confirm phone number could help clinicians provide safe care to patients.

We have asked the organisation to provide us with evidence that they have implemented the recommendations we have made on this case by the deadline we set.